Barriers to effective insulin treatment: the persistence of poor glycemic control in type 2 diabetes

Abstract

Background:

Contrary to longstanding recommendations on type 2 diabetes (T2D) management, the de facto standard of care in Canada includes lag times of many years prior to introducing effective glycemic control. Even patients transitioned to insulin may continue to experience poor glycemic control, with attendant diabetic complications, suggesting poor adherence or inadequate dose titration.

Objective:

To identify barriers to timely and effective use of insulin in T2D.

Methods:

PubMed searches were conducted to find research articles on insulin initiation, adherence and intensification. Also, because recent data on the consequences of intensive glycemic control may be taken as justification for relaxing glycemic targets, a secondary search on this literature was conducted, including the UKPDS and ACCORD trials, plus post hoc and meta-analyses of these data. No formal evaluation of level of evidence was conducted while researching this narrative literature review.

Findings:

Timely, effective glycemic control remains an important clinical goal but is complicated by patient, physician and treatment factors. Patient barriers to accepting insulin initiation include fear of hypoglycemia, injections and weight gain, and reluctance to accommodate the inflexible timing of scheduled insulin doses. Adherence issues, including dose omission, are common and are associated with some of the same factors. Fear of hypoglycemia also underlies many physicians’ reluctance to prescribe insulin. Caregivers’ failure to provide training or answer questions about insulin’s risks and benefits was also associated with low patient adherence. Poor communication may also be at fault when patients on insulin fail to titrate or intensify their treatment adequately. Conversely, glycemic control can be significantly improved by facilitating ongoing communication between patients and caregivers.

Discussion:

Although innovations in injectable therapy for T2D may help address the current pattern of poor glycemic control, improved communication between patients and caregivers is also a powerful approach and can be implemented with existing therapies.

Keywords::

• Diabetes
• Dose titration
• Hypoglycemia
• Insulin initiation
• Intensive glycemic control
• Treatment adherence
• Weight gain

Transparency

Declaration of funding

This work was sponsored by Novo Nordisk Canada. S.A.R. and H.D.T. received no financial support for their work on this manuscript.

Declaration of financial/other relationships

S.A.R. has received grant/research funding from Novo Nordisk, Eli Lilly, Boehringer Ingelheim and Brisyol Myer Squibb, and support for speakers bureaus from Novo Nordisk, Eli Lilly, Merck, Bayer and GlaxoSmithKline. H.D.T. declares no financial or other interest. The contribution of J.A. to the research and writing of this manuscript was made possible by the support of Novo Nordisk Canada. J.A. declares no other financial or other interest.

CMRO peer reviewers may have received honoraria for their review work. The peer reviewers on this manuscript have disclosed that they have no relevant financial relationships.

Acknowledgments

We thank Novo Nordisk Canada for providing the original impetus for us to undertake this research and for the opportunity to pursue this topic freely and independently.